senkinemmondta.hu - QUESTIONNAIRE

QUESTIONNAIRE

If you have already made an appointment with us, answer the questions below so we can get to know you better.

Who will you consult?

Name of parents

Country

City

ZIP code

Street name

Street suffix

House number

Phone number

E-mail address

Name of the baby

Date of birth

At which pregnancy week was the baby born?

Weight of birth

Lowest weight (when was it)(g)

When did you measure the lowest weight?

Actual weight (g)

Does the baby have any disease?

Yes

What would you like to talk about? How can we help you?

Has your breast size changed during pregnancy?

Yes

Do you have any of the following?

Hypothireosis

Hashimoto

PCOS

Insulin resistance

Diabetes

Other

Have you had breast injury or surgery?

Yes

Have you ever had depression?

Yes

Do you have a family member who has depression?

Yes

Have you planned to have your baby?

Yes

How was the baby conceived?

Which hospital did you give birth?

How did the delivery start?

How was the baby born?

What did you get during your delivery?

Oxytocin

PDA or spinal analgesia

Painkiller

Infusion

Nothing from the above mentioned

Did you get any treatment after delivery?

Yes

What kind of experience was the delivery?

Did you have a chance to breastfeed your baby at the delivery room?

Yes

How much and how did you have a chance to be together with your baby?

When and how the first breastfeeding happen?

Did you spend the whole day together at the hospital?

Yes

How often did you breastfeed the baby during the hospital days?

Did you get your baby any of the following during the hospital days

Pacifier

Bottle

Water

Tea

Water with sugar

Formula

Breast shield

Has your baby had icterus (high bilirubin level)?

Yes

Has your baby got any medicine, therapy (if yes, what was it)?

Yes

How many days have you spent in the hospital?

How many children do you have?

Do you have any lactation experience from before? (if so, tell us about it)

Yes

Tell us about your breastfeeding problem.

Who has helped you so far in latching?

Is the breastfeeding painful? (if so, where and when?)

Yes

After breastfeeding what can you notice on your nipple?

Twisted

White

Lipstick shape

Red

Scarred

Blistered

Has been or is your nipple injured?

Yes

Do you use nipple shield?

Yes, I use it

How often do you pump?

Do you take any medicine? (If so, what medicine?)

Yes

Do you use anything to increase milk supply? (If so, what do you use?)

Yes

How often does the baby breastfeed?

How is the baby’s behaviour after breastfeeding?

Does your baby get anything apart from breastmilk?

Nothing

Water

Tea

Formula

Pacifier

Bottle

How often do you weigh your baby?

How many pee does your baby have a day?

What is the colour of the pee?

How many poo does your baby have a day?

What is the colour of the poo?

How much time does the baby spend in hand?

Would you like to have a daily routine?

Yes

Where does the baby sleep?

Do you get any help in these days?

Yes

What kind of help did your nurse (védőnő) give you regarding your problem?

What did your paediatrician tell you?

Name of paediatrician

Address of practice

Name of védőnő (nurse)

I accept the Privacy Policy

Yes

I accept the statement related to the consultation

Yes

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